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Slide 1
Documentation & Requirements
Slide 2
Coverage Criteria & K Levels
Replacement Criteria
Repairs & Adjustments
Orthotic & Prosthetic Documentation
Requirements
Billing
Slide 3
Coverage Criteria &K Levels
Slide 4
A lower limb prosthesis is covered when the patient:
o Will reach or maintain a defined functional level ( K
level ) within a reasonable period of time
o Is motivated to ambulate and use the device including
motivated to put in the work to learn to use it properly.
o Their goal can range from Running, walking, walking
with assistance, standing with minimal walking, and
even transferring
Slide 5
• A determination of the medical necessity for certain components /
additions to the Px is based on the patient’s potential functional abilities.
• Potential functional ability is based on the reasonable expectations of the
prosthetist, and treating physician, considering factors including, but not
limited to:
o The beneficiary’s past history (including prior prosthetic use if
applicable)
o The beneficiary’s current condition including the status of the
residual limb and the nature of other medical problems
o The beneficiary’s desire to ambulate.
Slide 6
- The K-Level system was devised by Medicare as an attempt to classify prosthetic
components according to the patient population.
- Patients are assigned a K-Level, typically by their Prosthetist, which is used as a
guideline when choosing prosthetic components (i.e. feet or knees).
- An amputee's K-Level is designed to be fluid, meaning that an individual may
move through a variety of K-Levels throughout his/her life.
- The K Levels when classified at Evaluation are many times seen as a K Level
potential. This means the patient may have the POTENTIAL to reach the said
K Level in the next 2 – 6 months.
Slide 7
A few of the criteria that are taken into consideration are:
o Patient’s activity Level before amputation
• Very active, Active, Moderate, Low , Non-existent
• How long it has been since they walked and when they did what is any
assistive devices were used
o Any medical conditions that may limit their function
• Heart condition, Stroke, Limited lung function
o Manual Muscle Test & Range of Motion
• Limited range or contractures can effect the Level Potential. Also the patients
and their manual dexterity , and strength in both limbs ; especially the contra
lateral non amputated side, can all effect the decision.
Slide 8
Does not have the ability or potential to ambulate or transfer safely
with or without assistance and a prosthesis does not enhance their
quality of life or mobility.
- May have severe contractures caused by sitting for long periods of
time or other medical conditions that limit function
- MMT level of Grade 2+ or lower
Slide 9
• Has the ability or potential to use a prosthesis for transfers or
ambulation on level surfaces at fixed cadence.
• Typical of the limited and unlimited household ambulator
• MMT level of Grade 3 to 3+ Potential
Slide 10
• Has the ability or potential for
ambulation with the ability to
traverse low level
environmental barriers such
as curbs, stairs or uneven
surfaces.
• Typical of the limited
community ambulator.
• MMT Grade 3+ to 4 Potential
Slide 11
• These individuals can accommodate for "low level" environmental
obstacles including curbs, bumps and sidewalk cracks. They can
walk for limited periods of time but cannot typically vary their
walking speed.
Slide 12
• If amputees have the ability to vary their
speed and can traverse through a variety of
environmental obstacles, they are
considered to be a K-3. These individuals
can walk through a variety of
environments (grass, rocks, hills, sand
etc.) without difficulty. The prosthetic is
used for recreational and moderate
exercise activities
Slide 13
• Has the ability or potential for ambulation with
variable cadence.
• Typical of the community ambulator who has
the ability to traverse most environmental
barriers and
• May have vocational, therapeutic, or exercise
activity that demands prosthetic utilization
beyond simple locomotion.
• MMT Grade 4 to 5 Potential
Slide 14
Slide 15
• Has the ability or potential for
prosthetic ambulation that exceeds
basic ambulation skills
• Exhibiting high impact, stress, or
energy levels. Typical of the prosthetic
demands of the child, active adult, or
athlete.
Slide 16
Slide 17
• Use modifiers to indicate functional level
K0 , K1, K2, K3, K4
• The records must document the beneficiary’s current
functional capabilities and his/her expected functional
potential, including an explanation for the difference, if that is
the case.
• It is recognized within the functional classification hierarchy
that bilateral amputees often cannot be strictly bound by
functional level classifications.
Slide 18
The following items are included in the reimbursement for a prosthesis and, therefore,
are not separately billable to Medicare under the prosthetic benefit:
• Evaluation of the residual limb and gait.
• Fitting of the prosthesis.
• Cost of base component parts and labor contained in HCPCS
• base codes.
• Repairs due to normal wear or tear within 90 days of delivery
• Adjustments of the prosthesis or the prosthetic component made when
fitting the prosthesis or component and for 90 days from the date of
delivery when the adjustments are not necessitated by changes in the
residual limb or the patient's functional abilities.
Slide 19
Replacement Criteria
Slide 20
• Replacement of prosthesis or major
components must be supported by a new
Physicians order.
• Replacement of a prosthesis or prosthetic
component is covered if:
o Change in physiological condition of the
patient
o Irreparable wear of the device or part
o Repairs that will exceed 60% if the cost for
a new device
Slide 21
The time frame for a replacement socket according to Medicare guidelines is:
Socket Replacement :
6-12 months which is dependent on volumetric and anatomical
change
All New Prosthesis:
2 years unless there has been a functional level change or the
equipment was provided by another company and does not meet
the patients needs. i.e.: wrong level of equipment for patients
current or anticipated K Level.
Slide 22
Repairs & Adjustments
Slide 23
• A repair is a restoration of the prosthesis to correct problems due to
wear or damage.
• An adjustment is any modification to the prosthesis due to a change
in the patient's condition or to improve the function of the prosthesis.
• Maintenance which may be necessitated by the manufacturer’s
recommendations or construction and must be performed by the
prosthetist to be covered.
Slide 24
Prosthetic Documentation Requirements
Slide 25
• Suppliers must have an order from the
treating physician before dispensing a
prosthesis to a beneficiary.
• If the item(s) is delivered prior to obtaining
a detailed written order, the supplier must
obtain a dispensing order prior to delivery.
• The dispensing order may be written, faxed
or verbal.
Slide 26
• The dispensing order must include:
o A description of the item
o The beneficiary’s name
o The physicians signature ( if written ) or the supplier’s signature (
Verbal )
o The name of the physician
o The date of the order
The Supplier must maintain written documentation of the
dispensing order and this documentation must be available upon
request.
Slide 27
• In order for a Practitioner
to talk to and evaluate a
patient for a prosthesis
there must be a signed
order to do so.
Slide 28
• The dispensing written order must include:
o The beneficiary’s name
o A detailed description of each separately billed component
o The ordering physician’s signature
o The date the ordering physician signed the order and
o The start date of the order * If different from the signature
date
Slide 29
AFO & KAFO
L1906, L1932, L1960, L1932, L1960, L1990
As well as custom KAFO codes from L2126-L2136
AFO’s and KAFO’s that are custom fabricated are covered for ambulatory beneficiaries when the basic coverage criteria listed above and one of the following criteria are met:
1.The beneficiary could not be fit with a prefabricated AFO; or,
2.The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,
3. There is a need to control the knee, ankle or foot on more than one plane; or,
4. The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,
5. The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.
Slide 30
Knee orthoses L1832, L1843 and L1845 are
also covered for a beneficiary who is
ambulatory and has knee instability due to
a condition specified in any diagnosis
listed below
Slide 31 Diagnosis ICD-9
Rheumatoid arthritis 714.0 – 714.4
Osteoarthritis 715.16, 715.26, 715.36, 715.96
Meniscal cartilage derangement 717.0 – 717.5
Chondromalacia of patella 717.7
Knee ligamentous disruption 717.81 – 717.9
Rupture of tendon, non-traumatic - quadriceps tendon 727.65
Rupture of tendon, non-traumatic, site-patellar tendon 727.66
Pathologic fracture of femur 733.15
Pathologic fracture of tibia or fibula 733.16
Aseptic necrosis of tibia or fibula 733.49
Malunion of fracture – nonunion of fracture 733.81-733.82
Stress fracture of tibia or fibula 733.93
Congenital deformity of knee 755.64
Fracture of femur - lower end 821.20 – 821.39
Fracture of patella 822.0, 822.1
Fracture of tibia and/or fibula - upper end 823.00 – 823.42
Dislocation of knee 836.0 – 836.69
Sprains and strains of knee 844.0 – 844.2, 844.8
Late effect of fracture of lower extremities 905.4
Failed total knee arthroplasty 996.40 – 996.49, 996.66, 996.77, V43.65
Slide 32
or one of the following diagnoses
Slide 33
Diagnosis ICD-9
Multiple sclerosis 340
Hemiplegia, unspecified; dominant side; non-dominant side 342.90, 342.91, 342.92
Infantile cerebral palsy, unspecified 343.9
Paraplegia of both lower limbs 344.1
Mononeuritis of lower limb, unspecified 355.0, 355.2
Slide 34
Billing
Slide 35
• Payment for a prosthesis described by codes L5000-L5020 and L5400-L5460 is included in the payment when delivered to a Hospital if:
1. The prosthesis is provided to a beneficiary during Medicare Part A stay 2 days prior to the day of discharge;
2. The beneficiary uses the prosthesis for medically necessary inpatient treatment or rehabilitation and intends to take the prosthesis home.
Slide 36
• Claims for lower limb prosthesis provided to beneficiaries under Medicare Part B coverage in a SNF are submitted directly to the DME MAC.
• In addition, any claims for lower limb prosthesis provided in a SNF when the stay is under Medicare Part A, are also submitted directly to the DME MAC.
Slide 37
• For orthotics, Medicare will not pay for a
device if the patient is staying at a facility
(hospital or SNF) under Part A. If a device is
needed, the facility will be responsible for
payment.
• When the patient goes under Medicare Part B
(long term stay), then the device will be paid
for. Maximum allowable time for Medicare
Part A coverage is 100 consecutive days.
Slide 38
• Activities of Daily Living
• Prosthetic Usage Skills
• Education of Patient and
of Family members
Slide 39
• Pre and Post Prosthetic management
programs for various level amputees
• Shaping and care of the residual limb
• Exercise and functional training based
on patient’s age and medical
condition
• Safety issues with ADL
Recommended